Postsurgical mediastinal aspergilloma masquerading as malignancy

Abstract

A 70-year-old man with non-ischaemic dilated cardiomyopathy presented with symptoms of fatigue, chills and unintentional weight loss over the past 2 months. Initial evaluation revealed anaemia, peripheral leucocytosis and elevated inflammatory markers. Results of an oesophagogastroduodenoscopy, colonoscopy, blood bacterial and fungal cultures and bone marrow biopsy were negative. An ¹⁸F-FDG positron-emission tomography-CT demonstrated an indeterminate, intensely FDG-avid 5 cm × 2 cm × 5.6 cm × 6.7 cm mass centred within the junction of the superior vena cava and right atrium, suggestive of probable malignancy versus an inflammatory thrombus. After multidisciplinary consideration, patient underwent a diagnostic minithoracotomy and a thick fibrotic mediastinal mass was visualised and evacuated. The encapsulated mass contained thick, white creamy liquid that appeared to be purulent/necrotic material. The biopsies of the capsule wall on frozen section demonstrated fungal elements consistent with Aspergillosis species. Fungal culture confirmed diagnosis of Aspergillus fumigatus.

Keywords: cardiothoracic surgery; infectious diseases.

Figure 1

An indeterminant, intensely FDG avid (standardized pptake value (SUV), maximum 14.2), 5.2 cm × 5.6 cm × 6.7 cm mass is centred within the junction of the superior vena cava and right cardiac atrium.

Figure 2

CT angiography of chest showing an ill-defined mass (arrow) at the superior vena cava and right atrium junction.

Figure 3

Intraoperative findings of a fibrotic mass with tissue necrosis and purulent material in the encapsulated cavity.